Reply
Authors: Hannes Hagström, Ying Shang, Elliot B. Tapper, Axel Wester, Linnea Widman
Journal: Clinical Gastroenterology and Hepatology (2023)

We thank Drs Gajendran et al for their interest in our recent study.1Hagström H. et al.Clin Gastroenterol Hepatol. 2023; 21: 3336-3345.e2Abstract Full Text Full Text PDF Scopus (3) Google Scholar We re-emphasize that this was a study using real-life data, describing the treatment patterns after variceal bleeding in Sweden, from 2006 to 2020. The main result of the study was that secondary prevention is less than desirable and calls for improved education of clinicians who treat these patients to improve outcomes. Gajendran et al raised a few points that we clarify here, where possible. First, they questioned the treatment patterns regarding nonselective β-blockers (NSBB) before and after the index variceal bleeding episode and repeat upper endoscopy. We highlight that these proportions can be appreciated from the data in our original article (see Figure 1 in the original article). Next, they inquired about the dosing of NSBB. There was indeed no formal protocol that could be adhered to because this was a real-life study showing as-treated patients during the study period from all Swedish hospitals where these patients were diagnosed. We agree that the initial NSBB dose corresponding to 19 mg propranolol was low, but this indeed was the initial dose, which was likely to have been titrated upward after the first dispensation. Investigating drug dosages was not an objective of this study. Third, they inquired about causes of death and rebleeding. Rebleeding is hard to evaluate in this setting because repeat International Classification of Diseases coding for upper endoscopy and variceal bleeding might be made in patients when performing a control upper endoscopy, but also might be representative of new bleeding. We initially considered this analysis but elected not to pursue this strategy because of difficulties in interpreting the results without access to medical charts. Regarding causes of death, we agree in part, but overall mortality is what is most interesting to patients. This, and the time given to us by Clinical Gastroenterology and Hepatology to reply combined with vacation periods in Sweden, prevented us from analyzing this in detail at this time. Fourth, Gajendran et al asked about endoscopic findings during the initial bleed. Unfortunately, such details were not available in the registers used. Finally, they suggested some caution in interpreting the results owing to potential problems with bias in register-based research. Although we certainly agree that some degree of misclassification is probable in register-based studies, the accuracy of a diagnosis of variceal bleeding was validated externally in the register used, with a positive predictive value of 96%.2Bengtsson B. et al.Scand J Gastroenterol. 2020; 55: 1205-1210Crossref PubMed Scopus (38) Google Scholar Lastly, the study can be considered descriptive, and we do not make any causal claims. Given this, we strongly believe that the results, even if some degree of bias is present, clearly highlights that these patients are at risk for being undertreated. We look forward to studies examining the same question in other settings, and even more to initiatives trying to improve the care of these vulnerable patients. Secondary Prevention of Esophageal Variceal Bleeding: Still a Long Way to GoClinical Gastroenterology and HepatologyVol. 22Issue 3PreviewWe read with great interest the article by Hagström et al.1 published in Clinical Gastroenterology and Hepatology. This study is of considerable significance because it has tried to answer a key clinical question of what proportion of patients are being treated adequately after an episode of esophageal variceal bleeding. We also applaud the authors for adding important information to the literature, which can be used to improve the quality of care in patients with esophageal variceal bleeding. However, a few aspects of this study need further consideration. Full-Text PDF Secondary Prevention of Esophageal Variceal Bleeding Is Often Imperfect: A National, Population-Based Cohort Study of 3592 PatientsClinical Gastroenterology and HepatologyVol. 21Issue 13PreviewSecondary prevention of esophageal variceal bleeding is important to improve prognosis, but uptake of guidelines is unknown in a real-world setting. Here, we determined the proportion of patients receiving appropriate nonselective beta-blocker treatment and repeat upper endoscopy after a first episode of esophageal variceal bleeding within a reasonable time frame. Full-Text PDF Open Access